A patient is confused and has been restrained to prevent injury.Which of the following is a priority as the nurse plans care for the shift?

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Assess proper placement of restraint,skin integrity,pulses,temperature,color,and sensation of the restrained body part.Remove restraints at least every 2 hours or more frequently as determined by agency policy.If patient is violent or noncompliant,remove one restraint at a time and/or have other staff present while removing restraints.Chemical restraints are medications,such as anxiolytics and sedatives,used to manage a patient's behavior and are not a standard treatment for a patient's condition.Always attempt restraint alternatives before using a restraint.If a restraint is needed,always use the least restrictive device.Checking restrained patients last is not appropriate.Legislation emphasizes reducing the use of restraints.The Joint Commission and Centers for Medicare and Medicaid Services enforce standards for the safe use of restraint devices.

A Patient Is Confused and Has Been Restrained to Prevent